Apd Support Plan Form – Fill Out and Use This PDF

Agency for Persons With Disabilities

Support Plan/ Support Plan Update

Page 1

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Support Plan Development Date:

Support Plan Effective Date:

Support Plan Updates:

First:

Second:

Third:

Fourth:

Name:

Legal Status:

DOB:

SSN:

Guardians Name:

Medicaid #:

Guardian Type/Area:

Residential

Guardian’s Phone:

Address:

Guardian’s Address:

Phone:

Home:

Work:

Home District:

Residence/ Level of Care Codes

District of Residence:

Foster Care/ Small Group Care Codes

Support Plan Written By:

Intense

Moderate

Minimal

Name of Support Coordinator

Group Home And Residential Habilitation Center:

A

B

C

D

E

ICF/DD Level of

Care:

Personal Attributes (interest, talents, attributes, gifts, strengths, preferences, and communication style). How would you describe yourself to others? What things are you good at doing? What type of activities do you most enjoy? Who provided the information?

Future View (personal goals for the future (3-5 years). Things you want different in your life in the next 3-5 years. Where do you eventually see yourself living and working? What will you be doing for fun?

Agency for Persons With Disabilities

Support Plan/ Support Plan Update Page of

Name:

Support Plan Effective Date:

Agency for Persons With Disabilities

Support Plan/ Support Plan Update Page of

Name:

Support Plan Effective

Date:

Health Summary: Describe any health concerns and how it impacts on the person. What health concerns do you have? Describe the preventative health services that are needed to stay healthy.

( Attach additional pages and/or reports if needed.)

Who helps you manage				Relationship:				Phone:
your health care?
Assistive or Adaptive Equipment:			Yes			No

Identify glasses, dentures, equipment, etc. What adaptive equipment do you use and what is it used for?

Medications:

Yes, list below

No

Identify all meds: The name and dosage schedule, purpose and any problems/side effects being experienced. Any r problems, e.g., drowsiness, rashes, etc?

Current as of:

Medication Name Dosage and schedule Purpose or Diagnosis Problems/ Side Effects Noted

Note: Pages A, B, and C should be completed by the Support Coordinator Prior to the Support Plan Meeting.

Agency for Persons With Disabilities Support Plan/ Support Plan Update- Page of

Name:

Support Plan Effective

Date:

NOTE: Support coordinator has overall responsibility to coordinate the provision of all supports and services. Support coordinator is identified as responsible in situations in which the coordinator has a definite role/ specific task the coordinator is responsible for completing.

Agency for Persons With Disabilities Support Plan/ Support Plan Update- Page of

Name:

Support Plan Effective

Date:

Individual/Guardian Consent: I have participated in the development of the plan and I agree to the contents. I have been informed of my due process rights under Florida Statutes 120 and that I may appeal any portion of this plan. I understand that the purpose of this plan is to identify my or my family’s strengths, needs, preferences, and resources to help promote a positive quality of life. I understand that if my needs change, an update to this support plan may be needed. Supports should be identified according to my or my family’s needs regardless of the availability of funds. Supports and services needed to meet my needs will be sought from my personal resources, community resources and government resources. When government resources are necessary, they shall be provided based on the availability of general revenue funds.

Individual’s Signature:	Date:		Date Copy
			Sent:
	Date Copy Sent to Area:
Legal Representative’s Signature:	Date:		Date Copy
			Sent:
Printed Name and Telephone Number:	Relationship (parent, guardian advocate,
	POA)

Signature of Support Plan Participants

Relationship	Name /Address/Program (if applicable)	Date of	Date Copy
		Signature	Sent:

Signature of Support Plan Participants: Enter the relationship, and the name(s)/address/program (if applicable) of the individual(s) who are invited by the person and participated in the development of the support plan, and the date the support plan was signed. Provide the date the support plan was provided/mailed to the participant.